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Best Practices for Dental Offices Considering Expanding Operations Beyond Emergency Care to

Include Non-Urgent and Elective Procedures During the COVID-19 Pandemic

Overview

Although dental practices were never subject to an Executive Order to close during the shutdown

phase of the COVID-19 pandemic, the Office of Governor Ned Lamont, in consultation with the

Connecticut Department of Public Health (DPH) and statewide organizations representing dental care

practice, strongly advised dental practices to voluntarily limit procedures to those required as

emergencies and to suspend all elective procedures and routine non-emergency care, especially in

light of the scarcity of available personal protective equipment and the need for employers to

individually source that equipment in order to adequately protect their employees. As certain

Connecticut businesses begin to reopen starting on May 20th, several dental practices have begun

preparations for expanding their operations beyond emergency-only care to include elective

procedures and routine hygiene and health exams. It is recommended that, prior to engaging in

expanded dental practice activities, dental practitioners check with their insurer to fully understand

any potential liabilities that may arise from the decision to begin expanded care.

Currently, the Centers for Disease Control and Prevention (CDC) recommends that dental facilities

postpone elective procedures, surgeries, and non-urgent dental visits, and prioritize urgent and

emergency visits and procedures due to the risk of COVID-19 infection in the community. Dental

practices in Connecticut are bound by statutory language (CGS § 20-112(a)(15)) to adhere to CDC

guidelines for infection control in dental care settings and all Occupational Health and Safety

Administration (OSHA) requirements for safe workplaces. In addition, the American Dental

Association’s Principles of Ethics & Code of Professional Conduct stipulates that its member dentists

“have the obligation to provide a workplace environment that supports respectful and collaborative

relationships for all those involved in oral health care” and are responsible for “establishing and

maintaining a practice environment that supports the mutual respect, good communication, and high

levels of collaboration among team members required to optimize the quality of patient care

provided.”

As with all other industry sectors that are beginning to slowly expand operations, the most important

consideration in expanding operations in dental care settings will be the health and safety of

employees and patients. Dental practices considering expanding their operations at this time must

exercise caution to prevent infection both in their staff and their patients. This includes ensuring strict

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adherence to the controls listed here, which are the minimum baseline of precautions needed to

protect their employees, their patients, and the overall public health in Connecticut. Given current

public health data that indicates continued significant risk for statewide community spread of COVID-

19 infection, dental care practices that are not able to meet the guidelines listed here by May 20th are

strongly advised to delay expansion of their operations beyond urgent care until they are able to meet

these guidelines. Dental practitioners should also make themselves aware of the most current

guidance from CDC, the Connecticut Department of Public Health, the Occupational Safety and Health

Administration (OSHA), and their professional organizations and check frequently for updates to

guidance documents from those organizations as well as the recommendations detailed in this

document.

Of note, individuals with known or suspected COVID-19 infection should not seek or receive dental

treatment in a dental office for either routine or emergency care. Dental and medical practitioners

should work together to determine how best to provide needed emergency dental care to individuals

with active COVID-19 symptoms.

While these guidelines represent best-practices for dental providers to begin to slowly expand their

operations in as safe a manner as possible, risks to patients and employees cannot be fully mitigated.

Patients who choose to seek non-emergency dental care during this time should be fully aware of the

potential risks. Patients should also consider the overarching guidance from DPH and CDC that has

been in place throughout this pandemic; specifically that individuals 65 years of age or older or with

underlying health conditions that put them at risk for infection with, or complications related to,

COVID-19 (including those with lung disease, severe heart conditions, diabetes, liver or kidney disease,

and immunocompromised individuals) should not seek non-emergency dental care at this time, but

instead should continue to “stay home and stay safe”. With those restrictions in mind, dental offices

are strongly advised to delay, to the extent possible, non-urgent procedures for patients 65 years of

age or older or those with underlying health conditions that put them at higher-risk from COVID-19

infection. More information about co-morbid conditions that can increase an individual’s risk of

complications related to COVID-19 infection can be found on the CDC website (see Further resources

section).

Employers are also strongly advised to consider these restrictions when deciding which of their staff

members will be recalled to work during this early phase. At a minimum, employers should allow

temporary modified duty assignments that remove higher-risk employees from potential exposure to

aerosols in favor of lower-risk duties. If modified duty is not possible, employers should consider

allowing higher-risk individuals who are uncomfortable returning to work during this phase to continue

to remain out of the office until such time as increased risk to those individuals is mitigated by a

significant decrease in community spread of COVID-19 infection.

The best-practices for dental offices outlined in this document are not intended to supplant any other

regulatory requirements, but only to summarize and clarify for dental practitioners interim

supplemental best-practice guidelines during the COVID-19 pandemic, put forth by CDC and other

federal authorities, state agencies, and professional organizations. Pursuant to CGS § 20-114(a)(15)

the Connecticut State Dental Commission has the authority to discipline licensed dental practitioners

for failure to adhere to the most recent version of the Centers for Disease Control and Prevention's

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guidelines for infection control in dental care settings. Currently, and by reference, those guidelines

include CDC’s Guidance for Providing Dental Care during COVID-19. The Connecticut State Dental

Commission has the authority to discipline any licensed dental practitioner found in violation of

Connecticut State Statutes governing licensed dental practitioners, including suspension or revocation

of an individual license to practice in the state.

Employees and patients are encouraged to report violations and/or conditions in their dental offices

that they feel are unsafe to the State of Connecticut Department of Public Health for investigation and

referral to the Connecticut State Dental Commission. Reports can be filed by visiting

https://portal.ct.gov/DPH/Practitioner-Licensing--Investigations/PLIS/Reporting-a-Complaint.

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1. Planning and Preparation

Prior to expanding dental office operations to include routine hygiene and other non-urgent care,

practice owners are strongly advised to:

• Make and Discuss a Plan: Share these guidelines with your employees and inform them of any

additional specific measures being taken in response to COVID-19. Discuss how these general

guidelines will apply to specific operations within your practice. Update office procedure

manuals to include appropriate guidance for staff.

• Program Administrator: Assign a clinician to serve as the program administrator who is

accountable for implementing these rules and ensuring compliance by patients and staff.

Encourage the program administrator to work closely with the practice’s OSHA Compliance

Officer to ensure that workplace health and safety objectives are met.

• Cleaning Plans: Develop cleaning checklists that incorporate these rules. Ensure that it is clear

which employees are responsible for implementing cleaning plans and how to do those tasks

safely and properly.

• Personal Protective Equipment (PPE): Estimate required PPE for employees and ensure at least

a 2-week supply prior to expanding operations. Employers are responsible for sourcing their

own supplies of PPE and must provide this equipment to their employees free of charge.

• Thorough cleaning: Complete a thorough cleaning (see Further resources section for guidance)

of facility prior to expanding operations, including but not limited to

− Bathrooms

− Desks and Countertops

− Doorknobs and other

common touch points

− Reception areas and glass

dividers

− Computer equipment

− Radiographic equipment

− Chairs and headrests

− Rolling carts

− All tools and instruments

• Log employees: Maintain a daily log of employees on the premises, as well as the clients

they interact with, to support contact tracing. Include documented temperature

screening and symptom surveys.

• Shifts: Stagger start/stop times to the extent possible as well as break times to minimize

contact across employees. Break rooms should be closed, and staff should be restricted

from congregating in break rooms or other common areas. Break activities that involve

food consumption should occur off-site.

• Operatories: Ensure that operatories and other procedure spaces have doors that close

completely or have another physical barrier (floor-to-ceiling or at least door height) that

prevents the free flow of air from the room into common areas during procedures.

Open bay operatories should leave designated bays open to maximize the distance

between patients to the extent possible. In cases where open bay operatories include

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procedures where aerosols will be generated, install physical barriers between chair

bays, if they do not already exist.

• Training: Institute a training plan (in-house or virtual if necessary due to social

distancing needs) with staff and ensure 100% staff participation in the program prior to

expanding operations. Ensure that staff completely understand the guidance for

expanding operations in dental practices, how the guidance applies to your particular

practice, and their roles and responsibilities (especially newly assigned responsibilities)

under this guidance. The Program Administrator and practice owner should monitor

staff compliance with this guidance and provide retraining if staff show a lack of

understanding.

− Note: All training shall be provided at no cost to the employee and during paid

work time. The training materials shall be presented in the language and at the

literacy level of the employees.

• Leave: Employers shall adhere to federal guidance pertaining to paid leave for employees and provide this guidance to employees. Guidance can be accessed at: https://www.dol.gov/agencies/whd/pandemic/ffcra-employee-paid-leave

• Whistleblower Protection: Employers may not retaliate against workers for raising concerns about COVID-related or other safety and health conditions. Additional information about workers’ rights and whistleblower protections can be accessed at: https://www.OSHA.gov. Workers can also report conditions in their workplaces they feel are unsafe to the US Department of Labor’s Occupational Safety and Health Administration by visiting https://www.osha.gov/workers/file_complaint.html.

2. Physical Space Setup

• Signage: Post conspicuous signage that reinforces new policies (include signage in

multiple languages where employees and/or clientele are not native English speakers),

e.g.,

− Visits by appointment only

− Social distancing, cleaning, and disinfection protocols

− PPE protocols for employees and for patients (e.g., patients must wear

face coverings or masks at all times, etc.)

− COVID-19 symptoms and instructions that patients should call to

reschedule, and staff should stay home if sick or experiencing symptoms

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• Social distancing markers and barriers: Install visual social distancing markers to

encourage patients to remain 6 feet apart (e.g., at the reception desk). If reception

desks do not currently include a glass or other physical barrier between patients and

staff, plexiglass or a similar physical barrier should be installed.

• Discrete work zones: Where possible, segment the workspace into discrete zones,

prevent movement between zones and close spaces where employees congregate (e.g.

hygienists work in a single operatory or other defined work zone during a workday to

minimize overlap)

• Shared equipment: Ensure that employees do not share equipment and that equipment

is not moved between examination rooms to the extent possible. If equipment is to be

used between exam rooms, it must be cleaned and disinfected between rooms.

• Ventilation: Ensure building ventilation systems are operating properly and

appropriately maintained. For offices with central HVAC systems, ensure that the

system is adjusted in such a way that dilution and filtration are maximized and that

dampers are fully open to bring as much fresh outdoor air into the system as possible.

Change system filters according to the manufacturers specifications and utilize the

highest-rated filter possible (MERV rating) that is compatible with your system. For

offices without central HVAC systems, ensure that stand-alone units (e.g., window air

conditioning units) are maximizing outdoor air brought into the space. Be careful to

ensure that examination rooms are not becoming pressurized and pushing room air into

common areas (i.e. maintain neutral air flow).

• Waiting Areas: Supply only enough seating in waiting rooms to support social distancing

or ideally, ask patients to remain in their car if staff are not ready to see them

immediately. Remove amenities non-essential to businesses' main function, including

− Magazines, pamphlets, other waiting room materials

− Customer-facing water and coffee machines

− Coat racks

• Touchless appliances: Install touchless appliances wherever possible, including

− Contactless payments

− Paper towel and soap dispensers

− Trash cans (ensure bins have lids)

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3. Health Screening

• Signs and Symptoms: CDC-defined signs and symptoms of COVID-19 including cough,

shortness of breath, or any two of the following:

− Fever

− Chills

− Repeated shaking with chills

− Muscle pain

− Headache

− Sore throat

− New loss of taste or smell

• Employees who exhibit the above symptoms should stay home and self-monitor for progression of symptoms that may indicate active COVID-19 infection. Employees presenting for work should complete a symptom checklist, including logging their current measured temperature. Employees shall inform their employers and follow state testing and contact tracing protocols if they become infected with COVID-19.

• Patients should be pre-screened for COVID-19 symptoms by telephone or tele-dentistry no more than 24-hours prior to their appointment (e.g., during an appointment confirmation call). Upon arrival to the dental office, patients should complete a symptom checklist and have their temperature measured by office staff using a touchless thermometer. Any patients exhibiting COVID-19 symptoms should be excluded from care that day and asked to reschedule for a later date after their symptoms have subsided or they have testing that rules out COVID-19 infection.

• Employers should notify the Connecticut Department of Public Health (CT DPH) when they become aware of any staff member who has been diagnosed with COVID-19, including whether that employee has provided direct patient care or not, so that appropriate contact tracing and monitoring can be performed. In addition, employers should keep themselves informed about continually updated requirements from CDC and CT DPH for employee symptom monitoring, provisions for continuing business activities, reporting requirements, and quarantine and isolation of healthcare workers and other staff potentially exposed to COVID-19 in their workplaces.

4. Work Practice Controls

In addition to the controls for the physical office space discussed previously (see Section 2), there are several work-practice controls that are strongly advised to further protect dental office staff and patients during the COVID-19 pandemic. These include, but are not limited to:

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• Extending appointment blocks for potentially aerosol-generating procedures (including hygiene) to allow a minimum of one hour for performing procedures within each procedure space and at least an additional 30 minutes of dedicated time for the hygienist or other clinician involved with the procedures to fully and appropriately clean and sanitize hygiene rooms/operatories and equipment, doff or appropriately clean contaminated PPE, wash hands (and face if necessary), and don clean PPE between patients

• Utilizing tele-dentistry where at all possible, including for discussions of patient concerns and video-assisted pre-examination to determine if presentation to the office is necessary

• Designating and isolating specific operatories to perform procedures with the potential to generate aerosols and limiting the number of staff involved in those procedures on any given day. Separate rooms should be designated for hygiene-only, recognizing that these rooms may also be subject to some amount of aerosol generation during active hygiene practices.

• Minimizing the use of certain high-speed or pressurized equipment in procedures to the extent possible within the parameters of standards of care. For example, ultrasonic scaling should be suspended at this time if possible, in favor of manual hand scaling and selective polishing should be performed to minimize the generation of aerosols. When procedures are being performed that are likely to result in the generation of aerosols, work-practices to capture or control the spread of aerosols should be utilized, as well as appropriate PPE for aerosols. Those practices include, but are not limited to:

− Limiting the duration of procedures where possible, and consider multiple visits for extensive procedures, if practical

− Using full-mouth rubber dams for restorative treatment, as appropriate

− Using four-handed dentistry and high-volume evacuators (HVE) to control aerosols and droplets

• Considering a pre-procedure rinse before starting any procedure to minimize the overall load of bacteria and viruses inside the patient’s mouth. Follow manufacturers’ specifications for rinse duration to ensure maximum efficacy.

• Washing hands frequently, using soap and water for at least 20 seconds (preferred method) or frequent use of an alcohol-based hand sanitizer. This includes before leaving and after entering any patient room, before donning and after doffing gloves or other PPE, after performing any cleaning or disinfection activities, and after touching any potentially contaminated surfaces.

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5. Personal Protective Equipment (PPE)

Guidelines for the appropriate level of PPE for dental office staff is dependent on their physical

proximity to patients and other staff, the time spent in proximity to patients and other staff,

and the specific procedures being performed. Staff involved in procedures or working in areas

where aerosol generation is likely are required to wear higher-level PPE than those who are

involved exclusively in lower-risk non-aerosol-generating workflows. Employers are responsible

for sourcing their own supplies of PPE and providing appropriate PPE to their employees at no

cost.

Non-NIOSH approved respirators, including “KN95” masks, are not an acceptable substitute for

NIOSH-approved N95 respirators and should never be used during aerosol-generating

procedures. Although the Food and Drug Administration (FDA) has approved the import of a

subset of “KN95” from certain manufacturers for use in the US, FDA has only stated that the

filter media of those “KN95s” is likely to be as effective as the media used for N95s. The

Occupational Safety and Health Administration (OSHA) and CDC have agreed that the tight-seal

fit around the face required of NIOSH-approved N95 respirators cannot be obtained in most

cases with “KN95” face masks, especially those with “ear-loop” strap designs. As such, “KN95”

face masks should not be used in dental practices other than for source control (i.e. in

situations where a surgical mask is considered sufficiently protective).

• For dental office staff performing or working in close proximity to aerosol-generating

procedures, including certain hygiene activities, appropriate PPE must include all of the

following:

− Tight-fitting N95 filtering facepiece respirator (preferably surgical-grade N95

resistant to droplets). N95 respirators must be fully fit tested to ensure proper

protection. Employers providing N95 respirators and employees using those

respirators must comply with the standards of a complete respiratory protection

program, as prescribed by the Occupational Safety and Health Administration

(OSHA), including having a written respiratory protection program, providing fit

testing, training, etc. More information is available at:

https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134

− Disposable examination gloves

− Goggles with side shielding

− Disposable gown (to be replaced between patients) or fluid-resistant lab coat

changed between patients (to be laundered)

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− Disposable (or washable) hair caps/bonnets and shoe covers (or designate shoes

to be wiped down frequently and remain in the workplace)

− Full face shield (single-use or clean/disinfect between patients)

NOTE: PPE that becomes soiled or saturated during procedures should be

removed and replaced prior to continuing. PPE that becomes damaged should

be removed and disposed.

• For dental office staff performing clinical care limited to examination, radiography, or

other non-aerosol generating activities and utilizing work-practices where aerosols are

not likely to be generated, appropriate PPE must include all of the following:

− Tight-fitting N95 filtering facepiece respirator (preferably surgical-grade N95

resistant to droplets), or level 3 surgical mask (at a minimum)

− Disposable examination gloves

− Dedicated work clothing that can be laundered (e.g. scrubs or lab coat) or a

disposable gown

− Goggles with side shielding

− Full face shield (single-use or clean/disinfect between patients)

NOTE: PPE that becomes soiled or saturated during procedures should be

removed and replaced prior to continuing. PPE that becomes damaged should

be removed and disposed.

• For dental office staff performing non-clinical care activities, including reception,

billing, or other general office work, appropriate PPE includes:

− Surgical mask, cloth mask, or other face covering that completely covers the

nose and mouth (for droplet source control)

− Disposable examination gloves, if exchanging items with patients or other staff

− Dedicated work clothing that can be laundered (e.g. scrubs or lab coat) or a

disposable gown

− Full face shield (single-use or clean/disinfect between patients) if interacting

with patients without some physical barrier

• NOTE: PPE that becomes soiled or saturated during procedures should be removed and

replaced prior to continuing. PPE that becomes damaged should be removed and

disposed.

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• For patients presenting to the dental office, a surgical mask, cloth mask, or other face

covering that completely covers the nose and mouth, must be worn at all times when

inside the dental office and not actively undergoing a procedure. If patients present to

the office without a face covering, staff may either provide them with a single-use

disposable mask (e.g. a surgical or procedure mask) or require them to leave and

reschedule their appointment.

6. Cleaning and Disinfecting

Cleaning and disinfecting procedures are an extremely important component of infection

control in dental practices, and their importance should be elevated in the face of the COVID-19

pandemic.

• Appropriate PPE must be worn for all activities involving potential exposure to patient body fluids, contaminated surfaces and equipment, and hazardous chemicals (i.e. disinfectants). Staff performing cleaning activities need to be adequately protected simultaneously from infectious and chemical hazards. Puncture resistant/utility gloves, masks, eye protection and gowns must be worn while handling contaminated instruments.

• Practices are strongly advised to schedule patient appointments in a manner that allows for complete disinfection of procedure rooms prior to the first appointment of the day, in between each patient, and after the last patient of the day.

• Clean and disinfect each room with an Environmental Protection Agency (EPA)-registered hospital disinfectant on list N of the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program from use against SARS-CoV-2. Follow the manufacturers’ instructions for use of all cleaning and disinfection products (i.e., concentration, application method and contact time).

• Doorknobs and other common touch points need to be wiped down routinely in addition to counters, chairs, cabinets, and other surfaces.

• If using an ultrasonic cleaner to remove instrument debris, ensure a lid is used and fits tightly over the unit to prevent introducing aerosols into the area. Ensure staff responsible for loading and unloading the ultrasonic cleaner wear proper PPE to protect against aerosol exposure from the machine. Follow all manufacturers’ guidelines for the use of your particular ultrasonic cleaner to prevent inadvertent aerosol release, including wait times between cycles and keeping units covered at all times.

• Designate clean and dirty areas in the sterilization area. Autoclave all critical and heat-tolerant reusable dental and dental hygiene instruments prior to use. Use chemical and biologic monitoring to ensure sterilization is effective and include the date and time of

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sterilization on all instrument packs. Keep all sterile instruments packaged until ready to be used for patient care.

Other cleaning/disinfection considerations:

• Hand sanitizer should be made available at entrance points and common areas where

possible

• Cleaning or disinfecting products and/or disposable wipes should be available near

commonly used surfaces where possible, e.g., phones, computers, credit card machines,

reception desk, light switches, and door handles

• Restrooms should be cleaned and disinfected frequently, implement use of cleaning log

for tracking. Clean multiple times a day if restrooms are used frequently by patients

and/or staff

Further resources:

CDC Guidance for Providing Dental Care during COVID-19

https://www.cdc.gov/oralhealth/infectioncontrol/statement-COVID.html

OSHA Guidance for Dental Practice during the COVID-19 Pandemic

https://www.osha.gov/SLTC/covid-19/dentistry.html

American Dental Association: Principles of Ethics and Code of Professional Conduct

https://www.ada.org/~/media/ADA/Member%20Center/Ethics/Code_Of_Ethics_Book_With_A

dvisory_Opinions_Revised_to_November_2018.pdf

American Dental Association: Return to Work – Interim Guidance Toolkit

https://www.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Int_Guidance_Treat_Pts.pdf

American Dental Hygienists’ Association: Interim Guidance on Return to Work

https://www.adha.org/resources-docs/ADHA_TaskForceReport.pdf

CDC Information for Healthcare Professionals: COVID-19 and Underlying Conditions

https://www.cdc.gov/coronavirus/2019-ncov/hcp/underlying-conditions.html

CDC Guidance for Cleaning and Disinfecting for COVID-19

https://www.cdc.gov/coronavirus/2019-ncov/community/reopen-guidance.html

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University of Washington Department of Environmental and Occupational Health Sciences:

Safer Cleaning, Sanitizing and Disinfecting Strategies to Reduce and Prevent COVID-19

Transmission

https://osha.washington.edu/sites/default/files/documents/FactSheet_Cleaning_Final_UWDEO

HS_0.pdf

Connecticut State Dental Commission

https://portal.ct.gov/DPH/Public-Health-Hearing-Office/Connecticut-State-Dental-

Commission/Connecticut-State-Dental-Commission

Phone: (860) 509-8000

Telecommunications Relay Service 7-1-1

410 Capitol Avenue, P.O. Box 340308

Hartford, Connecticut 06134-0308

www.ct.gov/dph

Affirmative Action/Equal Opportunity Employer